organization of hospital nursing, provision of nursing...
TRANSCRIPT
Organization of hospital nursing, provision of nursing care, and patient experiences with care in Europe
Luk Bruyneel
Katholieke Universiteit Leuven, Belgium
RESEARCH EXPERIENCE, FURTHER EDUCATION, LINK TO POLICY MAKING
WHO AM I: BUILDING A CAREER IN HEALTH SERVICES
2
2008 2009 2010 2011 2012 2013 2014 2015
Master in StatisticsMaster in Economic Policy
Research associate/project manager of RN4CAST: Registered Nurse
Forecasting in Europe
PhD study in patient related and
public health research
Post-doctoral research at King’s
College London
...
Master in Nursing
Young Gasteiner
Young Gasteiner
...
US 2009
RN4CAST Europe 2009-2010
RN4CAST ICPC 2009
Europe (12 countries)33,731 nurses in 486 hospitals11,318 patients in 210 hospitals
China (6 prov., 2 mun., 1 aut. reg.)9,698 nurses in 181 hospitals6,494 patients in 181 hospitals
South Africa (6 provinces)4,657 nurses in 62 hospitals
US (PA, CA, NJ, FL)27,509 nurses in 617 hospitalsMillions of patients in 430 hospitals
RN4CAST: A UNIQUE STUDY
NURSING: KEY TO PATIENT SAFETY
Portugal2,204 nurses and 2,223 patients in 31 hospitals
RN4CAST Extension 2014 3
RN4CAST: FINALLY GENERATING EUROPEAN EVIDENCE
NURSING: KEY TO PATIENT SAFETY
Work enviroment, staffing and patient experiences
Aiken et al. BMJ for RN4CAST
Staffing, educationand patient mortality
Aiken et al. Lancet for RN4CAST
4
Education and patient mortalityAiken et al. JAMA
Staffing and patient mortalityAiken et al. JAMA
Staffing and patient complication ratesNeedleman et al. NEJM
2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014
GENERATING WORLDWIDE EVIDENCE
NURSING: KEY TO PATIENT SAFETY
5
PhD
RN4CAST
2009 2010 2011 2012 2013 2014 2015
Migratory status and non-nursing tasksInternational Journal of Nursing Studies& Second book volume PROMeTHEUS
Nurse work environment and burnoutInternational Journal of Nursing Studies
Staff nurses’ versus managers’ perceptions of work environments
Medical Care
Care left undone and patient experiences with care
Medical Care Research and Review
+50 publications in international peer-reviewed journals
SAMPLEEurope10,741 nurses and 11,549 patients in 217 hospitals in 8 countries
6
CARE LEFT UNDONE AND PATIENT EXPERIENCES
CARE LEFT UNDONE AND PATIENT EXPERIENCES
WHAT IS ALREADY KNOWN
High quality care inheres in the interaction of nurses with patients
Increased research interest in process variables such as care left undone
NEW CONTRIBUTION
Patient experiences are an indicator of quality deficiencies in structures and
processes of nursing care
Emphasis of the synergy between nursing education and nurse staffing
7
STUDY AIMS
1. Specify the extent to which nursing care that is left undone mediates the
relationship between the organization of hospital nursing and patient
experiences with hospital care
2. Specify how the importance of tasks left undone, as an intervening variable,
is moderated by the effects of the educational level of hospital staff nurses
8
CARE LEFT UNDONE AND PATIENT EXPERIENCES
FINDINGS: VARIATION IN PATIENT SATISFACTION/CARE LEFT UNDONE
CARE LEFT UNDONE AND PATIENT EXPERIENCES
9
Patient survey Nurse survey
% Patients rating the hospital 9 or 10
% Patients definitely recommending the
hospital
Average number of clinical care activities left undone
Average number of planning/communication activities left
undone
Belgium46.50
(24.56-82.76)58.31
(19.23-80.77)1.79
(.66-3.32)1.99
(.36-2.94)
Finland58.70
(25.81-77.23)65.22
(35.71-8.00)1.31
(.15-2.92)1.43
(.60-2.73)
Germany47.42
(23.53-71.43)65.23
(17.65-85.71)1.76
(0.83-2.38)2.55
(1.83-3.48)
Greece41.96
(15.00-76.47)56.64
(20.97-84.62)3.20
(1.27-4.29)2.20
(0.75-3.10)
Ireland60.18
(36.00-80.00)74.10
(60.00-96.67)1.42
(1.00-2.15)2.27
(1.50-3.13)
Poland54.17
(33.57-76.32)56.61
(34.43-69.75)1.29
(0.62-1.95)2.09
(1.22-2.93)
Spain34.87
(0-68.18)54.11
(18.52-83.33)1.39
(0.83-1.92)2.08
(1.51-2.73)
Switzerland61.20
(36.11-100)76.94
(40.00-100)1.02
(0.45-1.88)1.58
(0.67-2.35)
FINDINGS: VARIATION IN NURSE STAFFING (PATIENTS PER NURSE)
CARE LEFT UNDONE AND PATIENT EXPERIENCES
Ireland 7.0 5.4-8.9
Switzerland: 7.9 4.6-12.6
Finland: 8.3 5.3-15.6
Greece: 9.86.3-15.5
Poland: 10.4 7.2-14.9
Germany: 13.0 7.5-19.2
Spain: 12.4 9.4-17.9
Belgium: 10.7 6.2-16.2
Weighted by hospital level10
FINDINGS: VARIATION IN NURSE EDUCATION LEVEL (% BACHELOR NURSES)
0
10
20
30
40
50
60
70
80
90
100N
ot
incl
ud
ed
CARE LEFT UNDONE AND PATIENT EXPERIENCES
54% 53%
0%
100%
26%
60%
22%
10%
11Weighted by hospital level
No
t in
clu
ded
No
t in
clu
ded
No
t in
clu
ded
12
Common identifiers
Country
(c)
Hospital
(h)
BE 1
BE 1
BE 1
BE 2
BE 2
NL 1
NL 1
ANALYTIC STRATEGY
Three linked data sources
Patient survey data
Patient
(p)
Rating of the hospital
(yphc)
1 0
2 0
3 0
6 .
7 0
1 0
2 1
Nurse survey data
Nursestaffing
(xhc)
Clinical careundone(mhc)
Education levels
(whc)
9.45 3.2 60.40
9.45 3.2 60.40
9.45 3.2 60.40
7.50 2.05 75.50
7.50 2.05 75.50
6.50 1.60 40.80
6.50 1.60 40.80
Adm. data
Teaching status
(chc)
0
0
0
1
1
0
0
IND. LEVEL SYSTEM LEVEL
CARE LEFT UNDONE AND PATIENT EXPERIENCES
13
ANALYTIC STRATEGY
Three-level (moderated) mediation
Level 1: Patient
Level 3: Country
Level 2: Hospital
IND
. SY
STEM
LEV
EL
Y𝑝ℎ𝑐 , 𝑜𝑢𝑡𝑐𝑜𝑚𝑒 𝑓𝑜𝑟 𝑏𝑖𝑛𝑎𝑟𝑦 𝑚𝑒𝑎𝑠𝑢𝑟𝑒𝑠 𝑜𝑓
patient experiences with care
Random effect 𝑢𝑐
Random effect 𝑢ℎ𝑐
xℎ𝑐 𝑠𝑡𝑎𝑓𝑓𝑖𝑛𝑔 , zℎ𝑐 𝑤𝑜𝑟𝑘 𝑒𝑛𝑣𝑖𝑟𝑜𝑛𝑚𝑒𝑛𝑡 ,wℎ𝑐 𝑛𝑢𝑟𝑠𝑒 𝑒𝑑𝑢𝑐𝑎𝑡𝑖𝑜𝑛 ,xℎ𝑐wℎ𝑐 𝑖𝑛𝑡𝑒𝑟𝑎𝑐𝑡𝑖𝑜𝑛 𝑒𝑓𝑓𝑒𝑐𝑡 ,mℎ𝑐 𝑚𝑖𝑠𝑠𝑒𝑑 𝑐𝑎𝑟𝑒 ,…
𝑚ℎ𝑐 = 𝛾0 + 𝛾𝑥𝑥ℎ𝑐 + 𝛾𝑤𝑤ℎ𝑐 + 𝛾𝑥𝑤𝑥ℎ𝑐𝑤ℎ𝑐 + 𝜀𝑗𝑘
CARE LEFT UNDONE AND PATIENT EXPERIENCES
FINDINGS
Patient experiences with carePatient-to-nurse ratio
Clinical care left undone
Education levels
Years of experience
Work environment
Non-nursing tasks
Structure Process Outcome
Overtime
INDIVIDUAL LEVELSYSTEM LEVEL
Planning/communication leftundone
14
CARE LEFT UNDONE AND PATIENT EXPERIENCES
GENERAL DISCUSSION
AVENUES FOR FURTHER RESEARCH
Evaluating cost offsets of nursing system delivery strategies
Extension to non-hospital settings
POLICY CONSIDERATIONS
Place a premium on well-educated nurses
… and effectively leverage nurses’ roles
… and allow nurses to engage in lifelong learning
Nurse staffing ratios
Mandate specific ratios
Matching skills and experience of nurses to the need of patients
Reporting staffing levels to the public/regulatory body
Level-specific interventions to create positive work environments15
